State governments don't always use the legislative route to bring about change. Two states recently took administrative steps to strengthen the hand of patients in managed care plans.In New Jersey, the Department of Health released HMO draft regulations that cover a host of issues including recertification, quality and access, the appeals process and financial standards. The rules represent the first revision of the state's HMO regulations in more than 20 years.

Under the proposed rules, HMOs would have to be recertified every three years. In the health access area, only physicians would be authorized to deny or limit medical services. HMOs also would be required to disclose to the state the financial incentives they offer participating physicians to make them hold the line on medical expenses. New York state is considering adopting a similar disclosure rule.

For members dissatisfied with a New Jersey HMO's decision to deny or limit coverage, an external appeals process would be established. After a public comment period, the rules are expected to become final in May. HMOs in the state worry that they are being singled out for more stringent regulations than those applied to other kinds of health plans.

In Texas, the insurance commissioner recently issued "fair play" rules for patients in managed care plans at the request of Governor George W. Bush, son of the former president, who earlier had vetoed a "patient protection" bill that was backed by the state medical association.

Effective Jan. 1, the regulations require that patients receive "reasonable" advance notice before an HMO drops their doctor or dentist from its provider network. The rules also prohibit HMOs from using any financial incentives that induce providers to limit "medically necessary" services. Retaliation against insured individuals or against physicians "reasonably complaining on behalf of their patients" also is prohibited.

The rules provide a review procedure for physicians and dentists who are removed from a plan's provider list. Texas Insurance Commissioner Elton Bomer announced the new rules with the hope that they would "smooth the rough edges of managed care without undercutting its strengths.

"Texans will see that we can give patients and providers a fair shake while preserving managed care's effectiveness in containing health care costs," added Bomer.

Laws Assuring Ob/Gyn Access: A Bad Precedent?

The growing trend to mandate permission for women patients covered by managed care plans to have direct access to their Ob/Gyns is expected to continue in the 1996 state legislative session. Eight states passed Ob/Gyn laws in 1995, and more will follow, says Dan Stech, a field representative in the state government relations office of the Englewood, Colo.-based Medical Group Management Association. Connecticut, Louisiana, Maryland, Mississippi, North Carolina, Oregon, Utah and Washington enacted laws that allow women to see their Ob/Gyns without going through a gatekeeper physician first.

In general, the legislation permits women to choose an Ob/Gyn participating in a managed care plan as their primary care doctor, and to see that physician at least once a year. "This is a fairly popular legislative initiative," says Stech.

Of course, some insurance companies allow direct access to Ob/Gyns even without state laws requiring them to do so. Critics of the move to guarantee such access by legislation say these laws could set a troubling precedent for managed care organizations as other specialties seek similar legislation to assure patient access.

— Joan Szabo

Managed Care’s Top Ten Articles of 2016

There’s a lot more going on in health care than mergers (Aetna-Humana, Anthem-Cigna) creating huge players. Hundreds of insurers operate in 50 different states. Self-insured employers, ACA public exchanges, Medicare Advantage, and Medicaid managed care plans crowd an increasingly complex market.

Major health care players are determined to make health information exchanges (HIEs) work. The push toward value-based payment alone almost guarantees that HIEs will be tweaked, poked, prodded, and overhauled until they deliver on their promise. The goal: straight talk from and among tech systems.

They bring a different mindset. They’re willing to work in teams and focus on the sort of evidence-based medicine that can guide health care’s transformation into a system based on value. One question: How well will this new generation of data-driven MDs deal with patients?

The surge of new MS treatments have been for the relapsing-remitting form of the disease. There’s hope for sufferers of a different form of MS. By homing in on CD20-positive B cells, ocrelizumab is able to knock them out and other aberrant B cells circulating in the bloodstream.

A flood of tests have insurers ramping up prior authorization and utilization review. Information overload is a problem. As doctors struggle to keep up, health plans need to get ahead of the development of the technology in order to successfully manage genetic testing appropriately.

Having the data is one thing. Knowing how to use it is another. Applying its computational power to the data, a company called RowdMap puts providers into high-, medium-, and low-value buckets compared with peers in their markets, using specific benchmarks to show why outliers differ from the norm.
Competition among manufacturers, industry consolidation, and capitalization on me-too drugs are cranking up generic and branded drug prices. This increase has compelled PBMs, health plan sponsors, and retail pharmacies to find novel ways to turn a profit, often at the expense of the consumer.
The development of recombinant DNA and other technologies has added a new dimension to care. These medications have revolutionized the treatment of rheumatoid arthritis and many of the other 80 or so autoimmune diseases. But they can be budget busters and have a tricky side effect profile.

Shelley Slade
Vogel, Slade & Goldstein

Hub programs have emerged as a profitable new line of business in the sales and distribution side of the pharmaceutical industry that has got more than its fair share of wheeling and dealing. But they spell trouble if they spark collusion, threaten patients, or waste federal dollars.

More companies are self-insuring—and it’s not just large employers that are striking out on their own. The percentage of employers who fully self-insure increased by 44% in 1999 to 63% in 2015. Self-insurance may give employers more control over benefit packages, and stop-loss protects them against uncapped liability.